Abstract
There are now a number of multi-author texts available on chronic fatigue syndrome (CFS) which review research from a wide range of medical specialist perspectives. This is the longest and most detailed I am aware of so far. In the book's preface the authors describe CFS as ‘a complex, sometimes controversial and often confusing condition’. It is hard to argue with this. The problem is that the medical research community's response is to research this clinical population from various specialist perspectives. On current trends the next general textbook on CFS will be running into several volumes! I am afraid that as I read this comprehensive text, the question in my mind was whether this type of publication is getting us anywhere. Focusing on CFS without context leads to confusion and bewilderment.
The authors argue that the compilation of this multiauthor, multidiscipline text is necessary because CFS is an ‘emerging illness’. It is more accurate to say that emerging medical research technologies are being brought 480 BOOK REVIEWS to bear on an old clinical problem. Cogent arguments have been presented in many places that the modern phenomenon of CFS appearing to emerge as a ‘new’ illness over the last decade or so may well be due to societal forces and changes in the nature of the doctor– patient relationship in modern times. This thesis has been beautifully outlined, in my view, in Edward Shorter's book [1]. Shorter's book is worthwhile because it puts CFS in a context that makes sense.
There was a time for texts which tried to encompass and draw together all the different areas of research endeavour in CFS, from post-infectious theories to neuroendocrine dysfunction and orthostatic intolerance if only to demonstrate the adage that medical researchers are like blind men examining and describing an elephant from different directions and are therefore reporting very different versions of what the same animal looks like. The best of these texts, although a decade old now, is edited by Gregory Bock and Julie Whelan [2]. I believe that the time for that sort of text has come and gone.
Huge lists of references from scientific journals covering the full range of research do not advance the situation unless very consistent and strict evaluation of the quality of the evidence base is presented simultaneously to the reader.
There has been a belief that the only way to present psycho-behavioural interventions to CFS sufferers in a manner they will find acceptable is to embed it among rafts of biomedical-style research. I believe that things have moved on and that it is far preferable to talk about what you believe will help patients and develop your research accordingly. If the authors actually subscribe to an idea (which seems to me a sound idea) that clinicians should manage CFS patients by tackling three domains of the physical-behavioural, the psychological and the social-interactive (part of Phase-Based Interventions, Chapter 22) by supporting a patient through crisis, stabilization, resolution and integration phases they should get straight down to stating this and then justifying their position. It would make for a much shorter and more useful book.
The problem, for me, in compiling such an apparently all-encompassing book is that it may confirm in the mind of any CFS sufferer who may read it that the medical profession is unsure how to tackle the clinical dilemma of medically unexplained physical and mental fatigue. More useful for both CFS sufferers and doctors, and especially psychiatrists, in my view, are the chapters in books which report on particular rehabilitative or therapeutic strategies that have been developed, based on clear theoretical underpinnings, and then scientifically tested. An example would be Michael Sharpe's chapter on chronic fatigue in Clark and Fairburn's text on applications of cognitive behaviour therapy [3]. The reader can evaluate the rationale and evidence for the therapeutic approach proposed in a more useful clinical context. This leads to a potential course of action utilizing a skill base.
In my experience the trap with CFS is to assume that because there is no consensus, nothing can be done and recovery should not be expected. I believe scientific consensus will never be reached, just as consensus was never reached about the cause and management of neurasthenia a century ago. Nevertheless, many patients will recover and all the more quickly if their medical attendants remain optimistic and can develop a consistent and practical plan of action.
I am afraid I don't see how this style of book will advance that cause.